title: Near-infrared fluorescence imaging: emerging applications in robotic upper urinary tract surgery.
abstract: BACKGROUND
  Near-infrared fluorescence (NIRF) imaging is a technology with emerging applications in urologic surgery.
  
  
  OBJECTIVE
  To describe surgical techniques and provide clinical outcomes for robotic partial nephrectomy (RPN) with selective clamping and robotic upper urinary tract reconstruction featuring novel applications of NIRF imaging.
  
  
  METHODS
  Data from 90 patients who underwent successful RPN with selective clamping or upper urinary tract reconstruction utilizing NIRF imaging between April 2011 and October 2012 were reviewed.
  
  
  METHODS
  We performed RPN utilizing NIRF imaging to aid with selective clamping and upper tract reconstruction with NIRF imaging, the details of which are outlined in this paper and the accompanying video.
  
  
  METHODS
  Patient characteristics, perioperative outcomes, and complications were analyzed.
  
  
  CONCLUSIONS
  Of the 48 RPN patients for whom selective clamping was attempted successfully, median estimated blood loss was 200.0 ml, warm ischemia time was 17.0 min, and median change in estimated glomerular filtration rate was -6.3%. There was a 12.5% complication rate, and all complications were Clavien grade 1-3 (14.3%). The upper urinary tract reconstruction utilizing NIRF imaging was performed in 42 patients and included pyelopasty (n=20), ureteral reimplant (n=13), ureterolysis (n=7), and ureteroureterostomy (n=2). Radiographic and symptomatic improvement was observed in 100% of the pyeloplasty, ureteral reimplant, and ureteroureterostomy patients and 71.4% of ureterolysis patients, for an overall success rate of 95.2%. This study is limited by the small sample size, the short follow-up period, and the lack of a comparative cohort.
  
  
  CONCLUSIONS
  Our technique of RPN with selective arterial clamping and robotic upper urinary tract reconstruction utilizing NIRF imaging is presented. This technology provides real-time intraoperative angiogram to confirm selective ischemia and may be an adjunct technology to confirm well-perfused tissue within a reconstruction anastomosis. Further investigation is needed to evaluate long-term outcomes of NIRF imaging in robotic upper urinary tract surgery and to delineate its indications.
authors.affiliation: Department of Urology, New York University, Langone Medical Center, New York, NY, USA.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Bjurlin
authors.affiliation: O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium.
authors.forename: Melanie
authors.initials: M
authors.lastname: Gan
authors.affiliation: Department of Urology, New York University, Langone Medical Center, New York, NY, USA.
authors.forename: Tyler R
authors.initials: TR
authors.lastname: McClintock
authors.affiliation: O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium; Department of Urology, University of Eastern Piedmont, Novara, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Volpe
authors.affiliation: Department of Urology, New York University, Langone Medical Center, New York, NY, USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Borofsky
authors.affiliation: O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium; Department of Urology, O.L.V. Hospital Aalst, Aalst, Belgium.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mottrie
authors.affiliation: Department of Urology, New York University, Langone Medical Center, New York, NY, USA. Electronic address: michael.stifelman@nyumc.org.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Stifelman
mesh_terms: D003952:Diagnostic Imaging / Q000379:methods; D003950:Diagnostic Techniques, Urological; D005260:Female; D005453:Fluorescence; D006801:Humans; D007259:Infrared Rays; D007680:Kidney Neoplasms / Q000175:diagnosis* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000175:diagnosis* / Q000601:surgery*
keywords: Indocyanine green; Near-infrared fluorescence imaging; Robotic partial nephrectomy; Surgical technique; Upper urinary tract reconstruction; reconstruction